The new clinical education reform is coming. It is a big change in the teaching of medicine and, therefore, there are some concerns and fears on the part of those who will embrace this new syllabus.
Students are the main recipients of this renewal and, therefore, we couldn't help but listen to them. We share the opinion of two students who express their views of this new clinical education reform. They talk about the benefits of this education reform, but also about their concerns about the change.
Bernardo Alves was born on 20 June 2000 in Barreiro and, at the age of four, he moved to Lisbon. Throughout his childhood he attended schools, but ended up doing all his secondary education at Colégio Valsassina. He chose Science and Technology, in Secondary Education, because he thought it was the area that best suited his characteristics and because he had a naive dream since he was a child of curing cancer. In high school, he was lucky to have an excellent Biology professor who allowed him to conduct research projects with researchers from different universities, from Beira Interior to the University of Aveiro and the iMM itself.
Fortunately, these projects were recognized at some congresses and conferences and he had the opportunity to, for example, present a work at INTEL ISEF 2018 in Pittsburgh, among other experiences and awards. And, if these experiences were fundamental to his personal and professional growth, they were also essential to realize that a full-time job in a laboratory was not something he aspired to in his life. Thus, Medicine emerged naturally and currently he says with certainty that it was the right decision.
Finally, at FMUL he contributed to Faculty projects, among which Solvin’IT and the School Council, among others, stand out.
How do you see this new Education Reform?
Bernardo Alves: As a year 3 student, I think I cannot fully understand the importance of this reform as I will never know what pre-reform clinical teaching was like. However, from what I tried to investigate and know, it seems to me an excellent opportunity for the FMUL and its students, given that the last time the syllabus was updated was in 2006/2007 and, as a reference Faculty, we have to always try to be updated. This reform has been worked on for many years and the principles by which it is governed (lower tutor/student ratio; integration of Medicine/Surgery; assessment based on outcomes, among others) seem to me to be positive ideas that will contribute to the better training of students at the Faculty of Medicine of the University of Lisbon. So, I would say that I look mainly at this reform with hope.
As a student and member of the Faculty's governing body, what is your opinion on this reform?
Bernardo Alves: This last year, the School Council allowed me to have greater contact with the reform and with the preparation for its implementation. From this contact, I could see that this reform has been being prepared for many years by very competent people, both lecturers and students, and it was not implemented this year just because of SARS-CoV2. Thus, I believe that this reform is well structured and organized, the result of the years of work put into it and, most important of all, it is based on good pillars. Also, I believe it was necessary to update our training.
Even so, once the reform is implemented, it is also our responsibility to monitor and detect its possible negative points and change them with a view to improving the quality of student training.
What are the students' expectations regarding this reform?
Bernardo Alves: First of all, it is necessary to point out that I am not able to speak for all the students, I can only refer my opinion and that of some colleagues with whom I have been discussing this topic. Bearing this in mind, I believe that the general expectation is that the reform will improve the education and training of future doctors, since this is the main objective of FMUL and what students expect from it.
From the conversations I have had with my colleagues, this reform is seen with hope, but also with some apprehension. I believe that it is a result of fear of the unknown - something normal and that will only be completely demystified next year, when we are actually experiencing the changes. While it is natural to have some resistance to change and a tendency to accommodate, it is crucial to have changes because only them lead to progression. It is, however, also necessary to guarantee moments of reflection and debate about these changes and possible necessary adjustments.
As an example, the idea of an integrated assessment is something that some students fear. On the other hand, the decrease in the tutor/student ratio is one of the aspects that seems to have been received with great enthusiasm.
How will the students adapt?
Bernardo Alves: Since the students experiencing the reform are not familiar with the previous programme, I believe the adaptation will be easy. Even so, there will be several meetings throughout the semesters to listen to the students, in order to make the necessary adjustments, facilitating the adaptation and correcting any flaws.
What improvements will this Reform bring to medical education?
Bernardo Alves: This reform will update the syllabus taking into account the shortcomings detected since the implementation of the previous 2006/2007 programme (both by internal and external reviewers of Best Evidence in Medical Education (BEME) and the evolution of pedagogy and medical education. The outcome-based education concepts, the SPICES curriculum (Student-centred; Problem-based; Integrated; Community-based; Elective-based; Systematic), the reduction of the tutor/student ratio, the integration of Medicine/Surgery in order to unite both and dividing the semesters according to systems, among others, are pillars of this change and proven effective methods in the teaching of Medicine. Next year, we will have to put these theoretical concepts into practice and later assess whether they are really bringing about improvements in education.
Are there any less positive aspects that, in your opinion, should be improved?
Bernardo Alves: Responding directly, I believe that there are a few controversial aspects of the reform among the student community, such as the integrated assessment of semester modules into a single exam and in an Objective Structured Clinical Examination (OSCE), although such a reduction in assessment occasions is important to have a more integrated medical knowledge, and the definition of passing criteria in the practical exam adapted to its difficulty, for example. However, I do not believe that they can be defined as less positive aspects. These decisions were based on bibliography and on the syllabi of other faculties and whose sole purpose is to improve the preparation of FMUL’s IMDM students. Reiterating an important idea, all these aspects will be evaluated later, to confirm whether they are really beneficial for training or not, since plans for evaluating the reform and its implementation have been defined.
Do you feel that students are concerned about these changes, especially those who go from year 3 to year 4?
Bernardo Alves: Yes, I think the students are concerned. As I mentioned in the previous answer, there are characteristics in the syllabus that can be frightening, such as sitting a single theoretical exam per semester with integration of subject areas and the definition of qualitative criteria for passing the practical exam, among others. I believe it can be safely said that it leads to increased levels of anxiety and pressure in students with just one “all or nothing” exam when compared to the alternative of having one exam for each subject area. It's something that needs to be taken into account. Having said that, I think that an integrated theoretical examination can also have advantages since they are more similar to real cases where patients can have multiple pathologies from different systems at the same time.
Finally, it should also be noted that most students received this information on 19 July, at a clarification session between two periods of exhausting exams. At such times, it is much easier to see things in a negative way.
I believe that it is necessary to go to the next year with a clear head, without preconceived ideas of how good or bad it will be, and then yes, evaluate the various aspects of the reform and how it can be improved. For my part, I can only guarantee that students will be heard, their opinion will be conveyed and their best interests will always be defended by students in decision-making bodies.
How does one train a good doctor?
Bernardo Alves: As a year 3 student, I don't feel able to give a reasoned answer to this very important question. So, just taking into account my personal beliefs and the limited experience that these three years at FMUL have given me, I believe that there are certain very important points, and I am sure that I must be forgetting others that are equally or more important.
The pre-clinical years (the first three years) are fundamental. I have a lecturer who says that in the first three years practically all the subject content is taught and the next three years are spent systematizing the knowledge previously acquired and learning how to act with that knowledge. I believe this and believe that a good preclinical syllabus is vital.
Additionally, tutors in the clinical years are critical. From the contact I have with older students, tutors “make” a subject area and can completely shape our opinion about it. For example, hiring new teachers potentially motivated to teach and reducing the tutor/student ratio is one of the measures of the new reform that I believe will contribute the most to improving medical training at the FMUL.
Finally, I think it is essential to encourage clinical reasoning and student practice. I believe that together they provide a very important foundation, allowing students to have a competent basic approach to patients and offering very solid pillars for specialized training.
Daniel Lourenço was placed as a General Training Intern at Beatriz Ângelo Hospital, in Loures, and was a FMUL student in the period 2014-2020. When talking to him, I realize that he conveys a lot of maturity when he explains that to choose the specialty, personal taste is not enough, which is the most important thing. Other factors count, such as lifestyle, salary, inherent working hours and also the type of work, which can be very different depending on the specialties. For all these reasons, he is still not sure which specialty to choose, because expectations and moments in life can influence the choice.
When I ask him if he can indicate two of the options he likes, it is curious to realize that he is so interested in the mind, Psychiatry, one of the areas that aroused his interest in the degree, as well as the performance and quality of life of people in the area of Sports Medicine. I am convinced that, whichever area he chooses, he will do it with full awareness of what lies ahead and do his best for his patients.
During our conversation, he always showed concern for the practical and clinical aspects of medicine, without neglecting the human component: communication with the patient is essential, and in general he sees this evolution of teaching as extremely positive, which, according to him, always has to happen.
When you had to choose, why FMUL?
Daniel Lourenço: I had good references about the faculty. Honestly I don't think there are big differences in relation to the other medical faculties in Lisbon. I don't think there is a difference in quality between them. Basically, the references were good, some people I knew had studied here and that was essentially the reason for my choice.
What did you think in terms of education and topics?
Daniel Lourenço: I realized that it is quite demanding, it is necessary to perform well, which is crucial.
I loved the group of friends I made. The group spirit and of mutual help created is an ally in the learning process. In terms of teaching, it became more or less obvious at the beginning that good solid theoretical foundations are required. In the early years, too much importance is paid to areas such as anatomy, by way of example, to the detriment of others that I think should have more relevance, such as physiology and microbiology. Especially these two will be much more important in the clinical years than human anatomy. Of course, anatomy cannot be overlooked, but in terms of weight, more emphasis should be placed on teaching physiology and microbiology compared to what happened when I was a student here in 2014. I have always believed that when one starts the clinical years, it is very helpful to have a good background in physiology, pathophysiology and microbiology.
What about the clinical years?
Daniel Lourenço: In relation to clinical years, the main thing is the fact that ideally there should be more and better contact with patients. The question of the tutor/student ratio is very important and it is something one is trying to change. It is very important to have a ratio that is as balanced as possible, because the learning process becomes more pleasant and the monitoring given to the student is higher. We also have to take into account that lecturers and tutors have their clinical activity. In my case, we always had good follow-up by excellent professionals, but I don't know if that happens to everyone. To improve this process, I think it would be ideal for the ratio to be more balanced.
Where do you think the Education Reform will be experienced?
Daniel Lourenço: Taking into account what is expected to happen, I believe there will be no disadvantages. There are changes that will be very good, namely the question of the ratio, the fact that theoretical classes are available and/or are taught digitally. Some subjects in the clinical years already resorted to this approach and it is positive in terms of learning. It's different from the experience of being in class and physically there, and maybe there are people whose learning will be better if they are there, but in general I think it's more advantageous for classes to have this digital support. Another thing is the change in the way learning is done, because during the degree, learning is very much focused on the hospital environment. The fact is that a very significant part of people who complete the degree will not work in a hospital environment. There are many more places in general and family medicine than in any other specialty. It is therefore important to adapt teaching to this circumstance. It is obvious that hospital education should not cease to exist, and it is an extremely relevant part of medical education, but it should be complemented with a pedagogical approach aimed at greater proximity to the community.
What do you think about bringing together surgical and medical areas?
Daniel Lourenço: Honestly, I didn't dislike how it was when I went through it, but maybe organizing by systems, talking about the heart, lungs, might make sense and it seems like a good measure.
And the importance given to foundation skills?
Daniel Lourenço: I think it's a measure that enriches learning. As the degree advances and comes to its end, it becomes more and more certain that having solid theoretical foundations is necessary. But it is not enough to be an excellent doctor, which is desirable. The human relationship part is very important, the health management part and having a notion in economic terms about how a hospital environment works is also important. Still, I believe that the relationship with the patients is more relevant. It is a complex issue, because it is not only necessary to be able to communicate with the patients, sometimes the circumstances in which the doctor is involved, even with excellent communication skills, are not the best: tiredness, shifts that never end... The ability to manage these situations, as a matter of fact, is only acquired with practice, but theoretical bases to improve the relationship with patients will always be welcome and correct.
There will be also changes regarding assessment, which will become more integrative, without oral exams...
Daniel Lourenço: In fact, it is difficult to evaluate someone orally in a fair, homogeneous and equitable way. The criteria can be subjective. How the person communicates, how he expresses knowledge and not the fact that he has that knowledge may be more important. I think it's great to have more homogeneous assessment methods. If the criteria are homogeneous, if the ability to apply knowledge is valued, and not just its possession, I think this is a correct measure, it is a better way to assess clinical capacity.
I also think that the way one plans and runs a multiple-choice test is extremely relevant.
In Gynaecology-Obstetrics and Medicine 2, the care and thoroughness with which the written assessment was outlined was obvious. If with this reform there is homogeneity of quality standards, raising them as much as possible, all those involved in the Faculty’s education process will benefit.
If you were to start year 4 now, how do you think it would be like?
Daniel Lourenço: I don't think that the idea is that there will be changes regarding difficulty, only that there is a better training process. Not that it wasn't good before, but the objective of medical training is to always be the best possible, meeting new needs and training professionals with more and better clinical qualities. So, honestly, I think that if I realized that the change was going to be in this regard (to improve the education process) I would feel comfortable.
In general terms, what are the main changes that you highlight as fundamental?
Daniel Lourenço: The constant search for strategies that help to optimize the process of acquiring theoretical and practical skills is valuable. For me, the issue of the tutor/student ratio is fundamental, as well as an education that takes more into account the provision of care to the community and the attribution of greater preponderance to practical training.
Leonel Gomes | Sónia Teixeira